Treatment of Opiate Withdrawal

Symptomatic treatment of the opiate withdrawal syndrome can often be achieved using a combination of drugs, such as benzodiazepines for anxiety and insomnia; loperamide or diphenoxylate and atropine for diarrhea; promet-hazine, which has antiemetic and sedative properties; and paracetamol or non-steroidal antiinflammatories for generalized aches.

Substitution treatment may be required in more severe cases of opiate dependence using a choice of methadone, buprenorphine, or dihydrocodeine. Because street heroin varies in purity, the starting dose cannot be accurately estimated on the basis of the amount of street drug used. Therefore, substitution therapy should be titrated against the symptoms and signs of withdrawal. For example, dihydrocodeine may be commenced in a dose of 120 mg three times a day, with the dose being increased if the patient has demonstrable clinical signs of opiate withdrawal (19).

Clonidine and lofexidine act as presynaptic a2-adrenergic agonists, which inhibit the noradrenergic storm associated with opiate withdrawal. Although

Table 5

Diagnostic Criteria for Opioid Dependence and Severity of Opioid Dependence

1. Opioids are taken in larger amounts or over a longer period that the person intended.

2. A desire for the drug persists, or the patient has made one or more unsuccessful effort to cut down or to control opioid use.

3. A great deal of time is spent in activities necessary to obtain opioids (such as theft), taking the drug, or recovering from its effects.

4. The patient is frequently intoxicated or has withdrawal symptoms when expected to fulfill major role obligations at work, school or home (e.g., does not go to work, goes to school or work "high," is intoxicated while taking care of children) or when opioid use is physically hazardous (such as driving under the influence).

5. Important social, occupational, or recreational activities are given up or reduced.

6. Marked tolerance; needs greatly increased amounts of the drug—at least 50% increase—to achieve the desired effect or a notably diminished effect occurs with continued use of the same amount.

7. Has characteristic withdrawal syndrome.

8. Opioids are often taken to relieve or avoid withdrawal symptoms.

In addition, some symptoms of the disturbance have persisted for at least a month or have occurred repeatedly over a longer period.

Severity

Mild Few, if any symptoms are present in excess of those required to make the diagnosis, and the symptoms result in no more than mild impairment in occupational functioning or in usual social activities or relationships with others.

Moderate Functional impairment of symptoms is between mild and severe.

Severe Many symptoms are present in excess of those required to make the diagnosis, and the symptoms greatly interfere with occupational functioning or usual social activities or relationship with others. Partial remission During the past 6 mo, there has been some use of the substance and some symptoms of dependence. Full remission During the past 6 mo, either there has been no use of opioids, or opioids have been used and there were no symptoms of dependence.

Fromref. 15a.

Table 6

DSM-IV Diagnostic Criteria for Opioid Withdrawal

A. Either of the following:

• Cessation of (or reduction in) opioid use that has been heavy and prolonged (several weeks or longer)

• Administration of an opioid antagonists after a period of opioid use

B. Three (or more) of the following, developing within minutes to several days after Criterion A:

• Dysphoric mood • Lacrimation or rhinorrhea

• Pupillary dilation, piloerection, • Yawning or sweating • Insomnia

C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

From ref. 165.

clonidine is effective in reducing most withdrawal symptoms, the drug has side effects of hypotension, sedation, and psychiatric problems, which render it unsuitable for use in police custody. By contrast, lofexidine has been used in detoxification from opiates with fewer side effects (20).

Maternal opiate withdrawal syndrome may be life threatening for the fetus, and special care should be taken to ensure that a pregnant, opiate-dependent woman's medication is continued while she is in custody. There should be a low threshold for referral for hospital assessment, especially in the third trimester.